Poverty and high unemployment in Detroit are potential contributory factors to depression.
Photograph: Getty

For Dr Doree Ann Espiritu, asking troubled souls about suicidal intent is always a delicate moment. “There’s always a fear that if you ask about suicide, you are giving them [the patients] an idea about what they can do,” the Detroit-based psychiatrist says. “Almost giving them a hint about what they might do.

“If you are not used to this type of work, it is something that you dread as a psychiatrist,” Espiritu says. “Either you have already had one, or you will have one. It is [seen as] something that is unavoidable.”

But in practice the approach has had remarkable results. Tackling the taboo of suicide head on has led to an impressive turnaround in parts of the city. The programme Espiritu jointly oversees has attained such clinical success over the past 14 years that it is inspiring myriad copycat schemes, including in the UK.

The method, established by Henry Ford Behavioral Health Services in 2001, is based on a clear principle: prevention, or the simple idea that suicide can be prevented if telltale signs leading up to it – including depression – are screened for in a mass, cohesive and coordinated fashion.

It's about establishing a blame-free environment

Dr Doree Ann Espiritu

Patients attending a Henry Ford family clinic with diabetes or taken to an emergency room for heart failure in south-east Michigan are now screened for mental health and depressive disorder. A depression diagnosis will result in the patient being treated immediately – even in a primary care unit that does not specialise in mental health – and then quickly passed on to the behavioural health unit.

A centralised IT system means results are trackable, and surveys and pertinent information are standardised in formats so they can seamlessly be used across Henry Ford clinics in and around Detroit. Coordination with non-medical practitioners, including social workers and family members, has been key. Patients can email their clinicians and attend regular drop-in appointments. Up to 12,000 patients using mental health facilities are tracked each year.

The programme has reduced suicide rates from 89 per 100,000 mental health patients in 2001 to 16 per 100,000 when data was last collected in 2013. This compares with a US national average of 230 per 100,000 mental health patients.

In the two years since the financial collapse of 2008 – when suicide rates were rising nationwide – the Henry Ford network of hospitals registered zero suicides per 100,000 patients. This result, a component of what the Henry Ford hospital has described as “perfect depression care”, has led to it branding the scheme as a “zero-suicide model”.

But not everyone is convinced. Patients treated at Henry Ford tend to be those with healthcare plans, which generally go hand-in-hand with full-time employment. And in a city with a poverty rate of 39%, a high unemployment rate and where many jobs are precarious and part-time, many Detroit residents are unable to access the zero-suicide programme.

While the main mental health clinic in question here is located in Detroit, four others are in suburban locations, where income levels tend to at least be double, if not quadruple, that of the residents of Detroit.

In poor communities, people who suffer from those mental health disorders often go undiagnosed

Andre Johnson, Detroit Recovery Project

Dr Brian Ahmedani, a researcher at the Henry Ford Health System Center for Health Services Research, says numbers have not been subdivided to see what proportion of patients are living in Detroit itself. But the fact that suicide figures at the start of the programme were lower than the national average could suggest a less deprived cohort.

Moreover, people losing their jobs – at great need of depression care – will also tend to lose their health insurance, meaning they will stop being captured in the study and numbers.

Andre Johnson, president of the Detroit Recovery Project, a private non-profit corporation providing services and programmes for residents of the city recovering from addiction and substance abuse, says about 95% of the 1,600 clients his organisation sees each year have no health insurance.

“In poor communities, people who suffer from those illnesses [mental health disorders] often go untreated, often go undiagnosed because of the limited resources,” he says.

While mental health disorders – especially of the depressive kind – are a big risk factor for suicide, the other is substance abuse. Combined, they are behind 90% of suicides, the Henry Ford programme says.

But prevention is nowhere to be seen on the streets of Detroit, Johnson says, with mental health issues the reason many of his clients turn to drugs or alcohol. “There’s very low prevention in the community. So what happens is people are acting out [using drugs and participating in criminal activity] and they have this condition, but hell, they didn’t even know they had this condition. And by the time they find out they are either on their way to prison or to jail.”

Still, for Espiritu the concept of eliminating suicide among a cohort of patients is nothing short of revolutionary. She says the extra costs incurred as a result of the scheme have been minimal. The changes have mostly been administrative and culture based.

More than anything else, she says, it is about “establishing a blame-free environment” where medical practitioners are supportive of each other and do not seek a colleague to pin a failure to. Leadership, Espiritu says, is also necessary in terms of changing the culture and conceiving the viability of a zero-suicide model.

For once then, it’s the international headline Detroiters may actually be pleased to have their name attached to: Detroit as a city at the forefront of suicide prevention.